Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, Service de Gynécologie Obstétrique, Paris, France; Université Paris Diderot, Paris, France; INSERM (Institut National de la Santé Et de la Recherche Médicale), U1153, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center, Obstetrical, Perinatal, and Pediatric Epidemiology Team, Paris, France.
Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, Service de Gynécologie Obstétrique, Paris, France; Université Paris Diderot, Paris, France; INSERM (Institut National de la Santé Et de la Recherche Médicale), U1153, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center, Obstetrical, Perinatal, and Pediatric Epidemiology Team, Paris, France.
Am J Obstet Gynecol. 2018 Apr;218(4):449.e1-449.e13. doi: 10.1016/j.ajog.2018.01.023. Epub 2018 Feb 5.
Management of noncephalic second twin delivery rests on the results of population-based retrospective studies of twin births that have shown higher neonatal mortality and morbidity for second twins with noncephalic, compared with cephalic, presentations after vaginal delivery of the first twin. Because these studies are flawed by data of questionable validity, do not report the obstetrical practices at delivery, and do not allow collection of potential confounding variables, we performed a national prospective study specially designed to evaluate the management of twins' delivery.
We sought to assess neonatal mortality and morbidity according to second twin presentation after vaginal birth of the first twin.
The Jumeaux Mode d'Accouchement study was a nationwide prospective population-based cohort study of twin deliveries performed in 176 maternity units in France from February 2014 through March 2015. The primary outcome was a composite of intrapartum mortality and neonatal mortality and morbidity. Neonatal outcomes of second twins born ≥32 weeks of gestation after vaginal delivery of the first cephalic or breech twin were compared according to the noncephalic or cephalic second twin presentation. Multivariable logistic regression models controlled for potential confounders. Subgroup analyses were conducted according to the breech or transverse presentation of the noncephalic second twin, and gestational age at delivery, before or after 37 weeks of gestation.
Among 3903 second twins enrolled in the study, 2384 (61.1%) were in cephalic and 1519 (38.9%) in noncephalic presentations, of whom 999 (25.6%) were in breech and 520 (13.3%) in transverse presentation. Composite neonatal mortality and morbidity did not differ between the noncephalic and cephalic group (47/1519 [3.1%] vs 59/2384 [2.5%]; adjusted odds ratio, 1.23; 95% confidence interval, 0.81-1.85). No significant difference between groups was shown for the primary outcome in subgroup analyses according to type of noncephalic second twin presentation or gestational age at delivery. Cesarean delivery rates for the second twin were lower in the breech than in the cephalic group (14/999 [1.4%] vs 75/2384 [3.1%], P = .003) and lower in the cephalic than in the transverse group (75/2384 [3.1%] vs 35/520 [6.7%], P < .001).
Noncephalic and cephalic second twin presentations after vaginal delivery of the first twin ≥32 weeks of gestation are associated with similar low composite neonatal mortality and morbidity. Vaginal delivery of noncephalic second twin is a reasonable option.
非头位第二胎的分娩管理取决于基于人群的回顾性研究结果，这些研究表明，与头位先露的第一胎阴道分娩后非头位的第二胎相比，新生儿死亡率和发病率更高。由于这些研究存在数据有效性有问题、未报告分娩时的产科实践，并且不能收集潜在的混杂变量，因此我们进行了一项专门设计的全国前瞻性研究，以评估双胞胎分娩的管理。
我们旨在评估第一胎头位阴道分娩后第二胎的头位与非头位对新生儿死亡率和发病率的影响。
Jumeaux Mode d'Accouchement 研究是一项全国性前瞻性基于人群的双胞胎分娩队列研究，于 2014 年 2 月至 2015 年 3 月在法国的 176 个产科单位进行。主要结局是产时和新生儿死亡率和发病率的复合结局。比较了第一胎头位或臀位阴道分娩后≥32 周分娩的第二胎足月儿的非头位或头位与新生儿结局。多变量逻辑回归模型控制了潜在的混杂因素。根据非头位第二胎的臀位或横位、分娩时的胎龄（37 周前或后）进行亚组分析。
在纳入的 3903 名第二胎中，2384 名（61.1%）为头位，1519 名（38.9%）为非头位，其中 999 名（25.6%）为臀位，520 名（13.3%）为横位。非头位组与头位组的复合新生儿死亡率和发病率无差异（47/1519 [3.1%] vs 59/2384 [2.5%]；调整后的优势比，1.23；95%置信区间，0.81-1.85）。根据非头位第二胎的类型或分娩时的胎龄进行亚组分析，主要结局无显著差异。与头位组相比，臀位第二胎的剖宫产率较低（14/999 [1.4%] vs 75/2384 [3.1%]，P =.003），与横位组相比，头位组的剖宫产率较低（75/2384 [3.1%] vs 35/520 [6.7%]，P <.001）。
第一胎阴道分娩≥32 周后，第二胎为非头位或头位，其新生儿死亡率和发病率复合结局相似。阴道分娩非头位第二胎是合理的选择。
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